GW1-2023-01868_Well Construction - GW1_20230222

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/YELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES i i
Well ConnactorName FROM To I DESCRIPTION
fL ft.
NC-3556-A
ft.NC Well Contractor Certification Number 13.OUTER CASING for multl�ased wells OR LINER ita linable
AAA Sweetwater Well & Pump, Inc. FRUM To DIAMETER THICKNESS nIATERrAi
ft. ft. in.
CompanyName 16.Ril!tM CASING
2.Well Construction Permit fi:0�i�nzz— '� FROM TO DIAMLM!t THICKNESS MATERIAL
List all applicable well construction permits(i.e. IC,County,State,Variance,etc.) iL 15 ft. 6 1(4 (i in' SDR-21 PVC
3.Well Use(check well rise):
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public ft. M in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. fL In.
Industrial/CommercialResidential Water Supply(shared) I&GROUT
Itri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fa Bentorib Screened
Monitoring Recovery ft. ft.
Injection Well:
_ ft. ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT'METHOD
Aquifer Test [DStormwaterDrainage fL r.
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary)
Geothermal(Heating/Cooling Return) rJOdicr(explain under 921 Remarks) FROM ft. ft.To DESCRIPTION der(color,har soil/rock 4pe,itraln sirs,eta)
4.Date Well(s)Completed:j':L[K/2.2—WeU iD# ft. ft. r(__.� .(,f
5a.Well Location: CT� csl'S1-k. n fL
me ALMA Facility IDN(ifopplicable) ft. it.
Facibty/Na
6dba&&n 6yweI ft. ft. �tidTFC.ilL1�l7
TPhyf i al�Adddress,City,and zip ft. fL
lk ILd e�� .%-n-7/ O g zi.REntnRKs
County Parcel Identification No.(PiN) Grouted On:
5b.Latitude and longitude in degreedminutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2L Certification:
• N W 01
11.112
6.Is(are)the well(s)INPermanent or OTemporary ignature of Clt tified Well Contractor f i Date
Lt Bp signing this form,I hereby certii-v that the avell(s)ivas(were)constructed In accordance
7.Is this a repair to an existing welt: []Yes or UC1Nc with 15A NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction it formatto and plain the nature ojthe copy ofthis record has been provided to the well owner.
repair under 921 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geopro"PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW i needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ra• SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (n) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdderent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �Q�� (ft.) Division of Water Resources,information Processing Unit,
01 water level is above casing,use"+" 1617 Mail Service Centeq Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Drilled above,also submit one copy of this form within 30-days'of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) (,
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:Timed 24a For Water Snpnhr&Infection Wells: In addition to sending the form to
/� p� the address(es) above, also submit one;copy of this form within 30 days of
13b.Disinfection type: CCH Amount: nC kL7y completion,of well construction to th county health department of the county
where constructed
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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